Creighton Center for Service and Justice :: Creighton University

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Fall and Spring Break Service Trip 2010 Coordinator Application

NetID:

First Name:

Last Name:

Please provide either residence hall information or your local address.

Residence Hall:

Room # (not box #):

Local Address:

Primary Phone Number:

E-mail Address:

Age as of first day of trip (Spring Break is March 6, 2010); if you are under 19, you and your parent/guardian must complete the consent form for your application to be complete - see our website for this form.

Age as of 03/06/10:

Home Address:

City:

State:

Major:

Year:

Freshman

Sophomore

Junior

Senior

Graduate/Professional

Faculty

Staff

Participant Type:

I am a 1st time coordinator applicant

I am a returning coordinator

I am on core team or am a committee chair

T-Shirt Size:

XXL

Student Organization Affiliations:

Please list two references. Include name, job title, and phone number where they can be reached. No students please.

Reference 1:

Reference 2:

Past Trips with the CCSJ (Location, Semester, and Year):

Emergency Contact Form

In case of emergency, please contact:

Primary Contact

Name:

Relationship:

Address:

City:

State:

Zip:

Daytime Phone:

Evening Phone:

Cell Phone:

Secondary Contact

Name:

Relationship:

Address:

City:

State:

Zip:

Daytime Phone:

Evening Phone:

Cell Phone:

What is the name and subscriber number of your private health insurance company?:

Please list any medicines, animals, or other allergens to which you are allergic:

Do you have any physical condition that we should be aware of when work is assigned?:

Yes

Please describe any physical conditions that we should be aware of:

Fall or Spring Break Service Trip Interest

I am interested in coordinating (Spring):

Any length of trip this Spring

A Full Week Trip this Spring

1st Half of the Week Trip this Spring

2nd Half of the Week Trip this Spring

I am not interested in coordinating this Spring

I am interested in coordinating (Fall):

Any length of trip this Fall

A Full Week Trip this Fall

1st Half of the Week Trip this Fall

2nd Half of the Week Trip this Fall

I am not interested in coordinating this Fall

Are you willing to drive a 12 passenger van?:

Yes

Possibly, with further training

Interviews: Wednesday, Oct. 28 - Friday, Oct. 30 (Sign-up in office)
Coordinator List Posted: Nov. 5
Week of Service: Friday, Nov. 6 - Friday, Nov. 13 (Sign-up in office or on online app)
Day of Formation: Nov. 14, 9 a.m. - 4:30 p.m. (Mandatory day of training; cannot apply if you cannot attend this entire day)
SBST General Info Night: Nov. 17, 9 p.m. (Harper Ballroom), Nov. 18, noon
SBST Participant Interviews: Nov. 30 - Dec. 4
Coordinator Meetings: Thursdays, Jan. 14, Jan. 21, Feb. 4, 9-10:30 p.m.
General Meetings: Jan. 28, Feb. 11, Feb. 25, 9-10:30 p.m., Harper Center Ballroom
Send-Off Service: Mar. 4, 9-10 p.m., St. John's
Reunion: Sunday, Mar. 21, 2-4 p.m.

Will you be able to attend ALL the above mandatory meetings?:

Yes

If you cannot attend one of the above meetings, please explain which one(s) and why:

DRIVING, NO-ALCOHOL, CELL PHONE, AND REFUND AGREEMENT

As a driver (if applicable), I bear in mind that I am responsible for the safety of my passengers and promise to drive safely, make sure everyone is wearing their seat belt, and observe the local traffic laws and speed limits.
At no time and under no circumstances will I consume alcoholic beverages or other illegal substances for the duration of the 2010 Spring/Fall Break Service Trip. This includes from the time I leave Creighton University until the time I return, even I am of legal age to drink.
I understand that for the sake of simplicity and community, the F/SBST program asks participants to leave cell phones at home (Coordinators will have cell phones to let loved ones know of safe arrival and for emergencies). If I choose to bring a cell phone with me, I will leave it off and packed in my bag unless an emergency arises.
If you are accepted and you decide not to participate in the service trip after the final drop day, your fees will be non-refundable.

By checking this box, I agree to the above statements:

I Agree

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Creighton University

Creighton Center for Service and Justice

Service Trip Coordinator Application

2010 Spring and Fall Break Coordinator Online Application